Pearls and Irritations

A ‘lockdown’ strategy that does not involve lockdown, a vaccine distribution policy that is dangerously inconsistent and covid testing facilities that cannot meet the demand generated by public health orders, are but some of the problems responsible for the continuing explosion of COVID-19 cases in Sydney
This week my granddaughter needed blood collected for a pathology test. The nurse who would collect the blood asked her “How are you with needles Sienna, I have a cream I can rub on your skin and after a few minutes the needle won’t hurt so much, would you like me to do that?” The 9 year old thought for a few seconds and said, ”No, let’s get it over and done with”.

How I wish our NSW Premier and her Department of Health thought the same way about tackling the breakout of Covid infections that has infected 900 that we know of and has more than 60 people of all ages hospitalised with serious illness.

Numerous highly qualified experts have labelled the current ‘soft lockdown’ a failure and urged the government to institute a real lockdown at least as prescriptive as the one that tamed Melbourne’s serious outbreak last year. Indeed we may need even tighter restrictions as we are dealing with a far more infectious form of the SARS virus.

Is it political stubbornness (Berejiklian is famously anti-lockdown), fear of the financial consequences or fear of a backlash from Covid weary citizens that is responsible for the intransigence? It looks to be a consequence of putting business interests ahead of the health and welfare of people. Whatever, the passionate rhetoric from the government has been so non-prescriptive that Sydney’s population sees lots or wriggle room to allow them to continue activities that should be unavailable at the moment.

So we hear daily, “My major message is this; do not leave your home unless it is absolutely necessary” but no definition of ‘necessary’ has been forthcoming, rather the suggestion is that, “you use common sense in deciding”.

So retail stores, offering anything but essential goods, are open. Not many customers maybe, but staff have to leave home, use public transport etc. In the Melbourne lockdown citizens were told that they could exercise outdoors for an hour a day, golf and tennis clubs were closed. We are advised we can leave our homes to exercise and our sporting clubs are open. How does leaving home to travel and spend a few hours having a round  golf at a club that must have staff at work to support your activity, sit with the “Do not leave your house——“, imperative?

Surely as a starting point for using the “common sense” approach to defining essential service, recommended by the Premier, individuals should be asking themselves if they are engaged in activities without which significant harm might result to others. Surely not all the people in a 4 km long queue in Fairfield for the testing of tradesman who must work across Sydney as they are deemed essential workers were really ‘essential workers’.

The reality is this. With each infected individual infecting 5 to 7 others at the moment, our world class contact tracers will not be able to find and isolate all asymptomatic spreaders and the soft lockdown now being experience will last until at least November when, optimistically, we may have enough people vaccinated to thwart the delta spread.

We need a hard lockdown now, one in which ‘essential’ is defined. Travel must  be minimised, in the Melbourne version  one could not travel more than 5 kms from one’s home No work on construction sites, no take-away food services, no retail stores open, etc.

Most importantly we know from local and International experience that hard lockdowns can work. As it is the soft lockdown is costing NSW more than a billion dollars a week and as it is prolonged, citizen weariness and mental health stresses become greater problems.

Vaccination strategies
We won’t escape from lockdowns and the threat of lockdowns until we have immunised the majority of Australians including children. Supply and  distribution problems are hindering our ‘roll out’. We are yet to deal with an incidence of ‘vaccine hesitancy’ of around 30% that must be overcome for all modelling suggests post-Covid life will require at least 80% of us to be protected.

As our Sydney outbreak featuring serious illness and at least two fatalities worsens, desperation is creeping into efforts to speed up vaccinations. This is the only explanation I can imagine for a very dubious decision.
Individuals who have had but one injection of the AstraZenica vaccine and are waiting for their scheduled second injection twelve weeks after the first are being urged to call their GP and see if they can get a second injection sooner. The argument proffered suggests that with the delta strain causing serious illness getting a little more protection sooner is a good idea.

Its acknowledged that better longer lasting protection is provided by waiting till twelve weeks for a second shot but people need better protection than is available from one shot now. Later people subjected to this suboptimal regimen could get a booster dose perhaps with the Pfizer vaccine.

Trials of the AZ Vaccine show that four weeks after one injection of the vaccine  protection efficiency is around 76%. Importantly you may still get infected but the risk of serious illness or death is much reduced. Not perfect but after trialing various time intervals between shot 1and two, investigators found a 12 week interval to be optimal. To their surprise when a second injection was given four weeks after the first, protection efficiency fell to 54%. How so?

Studies are ongoing but here is the likely scenario. The AZ vaccine can be likened to a space shuttle delivering astronauts to a space station. The astronauts are the crucial cargo but they must have a delivery vehicle of course. The AZ vaccine uses a harmless adenovirus to deliver just the part of the Covid virus that it uses as a key to get inside human cells.Our immune systems attack both the delivery vehicle and the cargo. A second dose of the AZ vaccine, four weeks after the first, may result in our immune system focussing  more on the foreign adenovirus than the bit of corona virus.

An earlier second dose when we are struggling to give a first injection to the 30%  of us over 60 who have not had a first injection is problematic. Also promising a third injection to have an individual maximally protected is also logistically difficult, all the more so if we promise to use the Pfizer vaccine for the third injection. Our use of the scarce Pfizer vaccine will, for the forceable future, focus on giving the unvaccinated a first injection.
Of interest to date, the optimal vaccination regimen turns out be a first shot of Pfizer followed by a shot of AZ.

Doesn’t matter which vaccine is used first, it’s the combination that gets the results. Telling Sydneysiders who have had a first AZ injection to call their GP to see if it is possible to move forward the date for one’s  second injection will cause all sorts of timetabling problems and many GPs will be confused by conflicting advise on the wisdom or otherwise of changing the dose scheduling.

AstraZenica Vaccine for Australians over 40 years

With the recent focus on the very rare but potentially serious complications that can follow receipt of the AZ vaccine a decision was made to recommend the vaccine only for those  of us over 60 years. As a result public confidence in the vaccine took a hit. Many over 60 said they would now wait for the Pfizer vaccine to be available. However as it is possible to get the AZ vaccine from a GP if you are over 18 and give informed consent thousands of young Australians are seeking vaccination.

The informed consent bit is all important  as, despite chances of complications being so low, all recipients must understand the potential complications and the symptoms that might suggest one is developing a complication. Early diagnosis, which can be established with two simple blood tests, and immediate treatment, markedly reduces even further the rare risk of serious vaccine induced illness. Every recipient must be equipped with knowledge of how in their particular circumstances, they could get urgent attention if needed.Obviously it is best for this knowledge to be imparted in a one on one conversation with a doctor or other appropriately trained health professional.

Now, with the delta variant causing serious illness in the young as well as older Australians, the government’s Covid advisory committee is recommending that the AZ vaccine be available to all over 40 at State run injection sites not just  GP’s offices.  In other words the risk/benefit ratio has shifted in favour of vaccination for people over 40 years. I worry about the ability (knowledge and time wise) of staff at mass injection sites to provide the detailed  advise needed for informed consent.

I would strongly suggest that the mass injecting hubs set up facilities for group information sessions with participants having the opportunity to ask questions.

Conclusion

We need to move immediately to a really hard ‘lockdown’, targeted and, in some cases, mandated immunisation for critical workers such as teachers, health  and aged care workers, quarantine staff, etc and a much better media campaign to encourage vaccination.

The current appalling attempt by the federal government to shock Australians into getting vaccinated by showing them a young woman struggling to breathe with just nasal prongs delivering oxygen is rightly much criticised. For those of us that lived through the error ridden ‘Grim Reaper’ AIDS shocker in the 80’s, this latest effort shows we have learnt little about infomercials that are accurate and empowering.